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Client#: 1047352 SE R VISTA10 <br /> ACORD. CERTIFICATE OF LIABILITY INSURANCE DATEtMIdgIpIYYY11 <br /> W0912025 <br /> THIS CERTIFICATE IS lSSUEati A$A hTATTI"I OF INFORMATION ONLY AND CONFERS NO Rt[iHT5 UPON THE CERTIFICATE HOLDIrR.THIS <br /> CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED I3Y THE POLICIES <br /> BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURtEFII AUTHORIZED <br /> REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. <br /> AOITAN the t srtlflca a holder Is an ADDITIONAL ,the polloy es)must have DITTO INSURED prov s ons Or Fe endorsed, <br /> If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement.A statement on <br /> this certiffcate does not confer any rights to the certificate holder In lieu of such endarsementil <br /> PRODUCER _ - - _.u.__...___�.-_ _ <br /> ml— <br /> USi Insurance Services NW I N E. Rhonda Scialpl <br /> 825 NE Multnomah Suite 1500 Arc o E,� 503 22q•834Q ,_....__.�,_ Nap 610 362.8130 <br /> Portland,QR 97232 A ll : rhonda.scialplijusixam <br /> 503 224.8390 INSURERISI AFFOFWINlI3ioViRAGIE AHAIC 0 <br /> INSURED --_ _.-__.-...-...,. INSURER A:Insurance Company of the West 27847 <br /> Service Station Systems,Inc. INSURER 0; _ <br /> 3224 Regional Parkway INSURER C: - <br /> Santa Rosa, CA 95403 INSURER 0; <br /> 1NSURERE., <br /> INSURER P <br /> COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: <br /> THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED AELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD <br /> INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CC NIT RACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS <br /> CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 1S SUBJECT TO ALL THE TERMS, <br /> EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. <br /> Lilt TYPE OF INSURANCE I�Srf• '(E++-. �_.•POLICY NUMBER Alulp.��yyyy LNN1D0 �..-{,{IYIrTS -.._-T —---- <br /> I COMMERCIAL GENERAL IJA9ILI7Y mm t:�: <br /> URRENCE { _ <br /> CLAIAIS•ATADE OCCUR <br /> PERSONAL&ADV INJURY ; <br /> GEN'L AGGREGATE LIMIT APPLIES PER: <br /> r GENERALAGGREGATE f <br /> T_ POLICY❑JECT LOC I PRODUCTS.COMPIOP AGO 6 <br /> OTHER° <br /> AU7OMOBELE LIAEILnY <br /> -- [ Eaaoc: 121MM Ii# <br /> ANY AUTO i + <br /> ONON 5CHEDULEo +II aCpILY INJURY(Per pereon) 6 <br /> ONLY AUTOS sonar INJURY(Per Rccldenl) S <br /> AUTOS ONLY HDN-aWNE{7 fl <br /> f AUTOS ONLY Par a�den[ •A S <br /> ulaeReLarA unE <br /> _ s <br /> Y OCCUR EACH OCCURRENCE $ <br /> r]CCES6 LIAtI CLAJMS-MADE AGGREGATE — - - <br /> s <br /> 11 OED RETENTION f <br /> 'WORKERS xPexsaTloHfAN0 EMPLOYERS' <br /> w F WLV507821801A 6144122 0B1Q412 K P��1 7Ti <br /> ANY <br /> LRORIT lAR7 lTIVE r►N <br /> EM N <br /> OFFI RMaEIPL NIA E,L.EACH ACCIDENT s11,000,00 <br /> 1Q0Q40- -- <br /> IManddev In NHI <br /> If E-L.DISEASE-EA EMPLOYEE 0,000,0011) <br /> yee,daecrlbe and er <br /> DESCRIPTION OF OPERATIONSbelow .-...-_--• _. E.L.VIS EASE.POLICY LIMrr s1,000 ll <br /> DESCRIPTION OF OPERATIONS!LOCATIONS 1 VFHICLE5(ACORD 101,AddlrlonaI Rvmnooa Sohedula,mny Ise aNschod If more space 19 roqulrad) <br /> A Waiver of subrogation applies where required by written Contact. <br /> -CERTIFICATE HOLDER _ CANCELLATION <br /> Service Station Systems,Inc. SHOULD ANY OF THE ABOVE DESCRIBED POLICIEB BE CANCELLED BEFORE <br /> THE EXPIRATION DATE THEREOF, NOTICE WILL EF DELIVERED IN <br /> 3224 Regional Parkway ACCORDANCE WITH THE POLICY PROVISIONS. <br /> Santa Rosa,CA 95403 <br /> AUTHORrzED REPREBENTATIVE <br /> --- --f �1886-2015 ACOR❑CORPORA;ION,All rights reserved. <br /> ACDRL]25(20111 1 Oil The reg <br /> ACORD name and logo are istered rnarks of ACORD <br /> PS49577197IM 49574723 BLtGZP <br />